Revista de chirurgie, oncologie, radiologie, o.r.l., oftalmologie, stomatologie. Chirurgie最新文献

The authors review the anesthesiology problems in hepatic patients on the one hand, and on the other hand they present their personal experience in anesthesia of patients with jaundice, upper digestive haemorrhage and hepatic coma. The conclusions of the study are the following: 1. The major hepatic functions which can interfere with anesthetic drugs and techniques are related to changes in the hepatic blood flow, the synthesis of proteins, homeostasis of carbohydrates, and especially the metabolization of medicinal drugs. 2. Hepatic patients presenting with jaundice, upper digestive haemorrhage, and hepatic coma raise special problems concerning preoperative preparations and anesthetic technique. Considering the risk factors which occur in the patient with jaundice denutrition, hypoalbuminemia and partially angiocholitis can be corrected by medical means. Hemostasis on hepatic patients with upper digestive haemorrhage is the most difficult problem, and also very controversial. There are not, at present, either infallible solutions or arguments in favor of hemostatic techniques (by compression, endoscopic haemostasis, or surgical hemostasis). The comatose patient is usually the final evolutive stage of the hepatic disease, and the mortality in this category of patients, indifferent of the therapy, is higher than 80%.

The authors present 4 cases of "effort" thrombophlebitis of the upper limb that were diagnosed both clinically and thrombophlebographically, and in whom classical therapy was applied: total rest, anticoagulants, elevation of the limb. All the cases had sequels of variable intensity, and in 2 of the patients Roos' transaxillary route was used which revealed a double anterior scalenus muscle insertion, and compressive fibro-sclerous tissue. The pathogeny of the affection makes mandatory the removal of extrinsic or intrinsic factors which may generate a new thrombosis or vascular and neurologic sequels.

Seven clinical observations are presented, illustrating the great diversity of traumatic lesions of the upper limb resulting from accidental self-shooting with bolt pistol. Although such accidents are rare a series of therapeutical attitudes, sometimes quite complex, are described.

A total of 76 cases were investigated in which fatal postoperative pulmonary embolisms were identified at the necroptic study. The following aspects are considered: the high incidence of fatal postoperative pulmonary embolisms in patients without favouring factors in antecedents (38%), and of patients operated for benign affections (50.6%); the rare occurrence of clinical signs of venous thrombosis in patients with fatal postoperative pulmonary embolisms (11.8%); the high incidence of early fatal postoperative pulmonary embolisms (46%)--in the first three days after surgery, of which 26.3% in the first 24 hours and the importance of their identification so as to exclude an erroneous interpretation of the cause of death, and finally the indications and the limitations of the prophylactic treatment with low amounts of heparin.

The authors have investigated the cyto-histologic correlation in 146 patients with primary urinary bladder tumours, and the causes which favor the false negative results. The authors found malignant cells in 92% of all cases, and stress the optimal conditions for the cytological investigation. It is considered that the study of the urinary sediment could replace successfully urinary bladder washing for the cytological surveillance of the patients operated for urinary bladder tumours. Diagnostic difficulties are presented, and the causes of the false negative results, which include: associated affections, special pathological conditions, therapeutical procedures, and technical details. The importance is discussed, of the urinary cytology study for the application of the associated immunostimulating therapy. On the basis of their personal experience the authors present succinctly the indications of urinary cytodiagnosis.

A case is presented, of endometriosis of the abdominal parietal scar after cesarean section, in a woman aged 35 years where emergency surgery had to be performed for a diagnosis of epiploic strangulation in an eventration point. The mechanisms involved in the development of endometriosis are discussed, as well as anatomopathologic, clinical and therapeutic aspects.

A prospective study was made with a view to analyse and to identify two particular forms of the post-thrombotic syndrome. The post-thrombotic syndrome of the shank can be recognized on the basis of the clinical and of the phlebographic examination. It has a serious prognosis and can be treated either conservatively or by surgery according to case. Its frequency is probably higher than it was presumed on the basis of the first observations. The post-thrombotic venous obstruction may be a cause of arterial ischemia during effort but this occurs only in very few cases. This particular syndrome is manifested as intermittent claudication which occurs in the clinical picture of chronic orthostatic venous failure. The probable mechanism is the direct effect of increased pressure in the arterial and venous circulation in vessels with normal walls, as a result of an important obstruction in the return circulation. Lumbal sympathectomy appears to improve durable claudication and hyperhidrosis.

The authors present two technical modalities for solving extensive defects of the duodenal wall which occurred during surgery for large duodenal ulcers, which in one case involved the entire anterior part of D1-D2. In another case the duodenal wall defect was due to tumoral invasion by cancer of the hepatic angle of the colon. The solution consisted in duodenoplasty with excluded intestinal loop in "Y", in the first case, and duodenoplasty on an omega loop associated with GEP in the second case.

Two cases are presented, with accidents of peridural anesthesia, Anesthesia of the entire brain stem, paralysis of the intercostal muscles, and of the upper limbs, apnoea and miosis that developed later indicate an extension of the anesthetic effects far higher that it could have been expected considering the technical details of the procedure. On the other hand the absence of any durable coma, of extreme mydriasis, and of severe arterial hypotension, as well as the relatively rapid retrocession of the additional effects of the administration of an anesthetic exclude the possibility of total rachianesthesia, and it can be concluded that there was an accidental injection of anesthetic in the extra-arachnoid subdural space.

Clinical, evolutive and therapeutical aspects were studied, of 66 cases of patients with pancreatic pseudocysts hospitalized in the clinic over a period of 27 years. Particular modalities of onset were, those of patients with duodenal stenosis, mechanical jaundice, ascites and pleurisy, those in whom symptomatology suggested kidney or cholecystic disease. The intraoperative diagnosis raises the problem of differentiating a retroperitoneal tumor, identifying the possible association with a pancreatic cancer, and the condition when the pseudocysts are found at a certain distance from the pancreas itself. The therapeutical methods are codified, but recidives are possible. Cholecystectomy removes the biliary cause of pancreatitis which can determine the development of pseudocysts. The death rate of these cases was 6.3%.